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Transfusion and Apheresis Science
Motivations and attitudes towards the act of blood donation among
undergraduate health science students
Maria José Gomesa,d
, António J. Nogueiraa,b,c,⁎
, Celeste Antãoa,d
, Cristina Teixeiraa,e
aInstituto Politécnico de Bragança, Campus de Santa Apolónia, 5300-253 Bragança, Portugal bMountain Research Center (CIMO), IPB, Bragança, Portugal
cCenter for the Research and Technology of Agro-Environmental and Biological Science (CITAB), UTAD, Vila Real, Portugal dHealth Sciences Research Unit: Nursing (UICISA: E), Núcleo da Escola Superior de Saúde, IPB, Bragança, Portugal eEPI Unit, Institute of Public Health of the University of Porto, Porto, Portugal
A R T I C L E I N F O
Keywords: Blood donation Undergraduate students Attitudes
A B S T R A C T
Background: Undergraduate students are a target for blood donation, as they constitute a young healthy and well-informed group.
Aim: To understand motivations and attitudes underpinning the act of blood donation among undergraduate health science students.
Materials and methods:Cross-sectional study enrolling undergraduate students of a College of Health Sciences in the Northeast of Portugal (January/February, 2017). Data collection tool was a self-administered questionnaire covering questions about motivations (n = 8) and attitudes (n = 5) towards the act of blood donation. Participants were classiﬁed by donation status into donors (one previous donation) and non-donors (never donated). Multiple logistic regression models were used to assess the association between each attitude and motivation on donation status. Odds-ratio (OR) and respective 95% conﬁdence intervals (95%CI) adjusted for potential confounders, were obtained.
Results:Out of 362 participants, 12.7% (n = 46) had ever donated blood and 56.5% (n = 26) of them were regular donors. Out of 316 non-donors, 88.0% (n = 278) will donate blood under request. There were no dif-ferences between donors and non-donors regarding the attitudes towards blood donation. From all motivations only“be a civic duty”had a signiﬁcant impact on donor status, such that participants reporting this motivation are more likely to be blood donors (OR = 2.58; IC95%:1.34-4.99) than their counterparts.
Conclusion:This study revealed that 80.0% of undergraduate health science students are non-donors, but they are available to donate blood under request. Campaigns and advertising methods focused on the emergent needs for blood donation could play an important role in the recruitment of new donors among undergraduate stu-dents.
Blood transfusion is an essential resource for health care systems, which contributes to increasing life expectancy and quality of life of people suﬀering acute critical illness or chronic diseases . Nowadays health care providers manage serious haemorrhagic complications after surgery, delivery or major accidents [2–5], severe blood disorders  and oncologic conditions [7,8] demanding blood transfusion. In these circumstances, a large volume of blood is required to meet so many diverse needs and many countries face the challenge of an increasing need of blood or its components.
Blood is a precious health resource as it is obtained from people who donate blood . Health services should provide suﬃcient blood to meet needs. Sourcing blood from voluntary non-remunerated blood donors (VNRBD) is the most eﬀective way to ensure safe and suﬃcient blood supply . Therefore, the recruitment and retention of VNRBD is a great challenge for health care systems around the world .
Voluntary non-remunerated blood donation has been considered an act of pure altruism . According to the Theory of Planned Beha-viour, the intention of donating is the most important determinant of the act of donating blood [10–12]. There is a body of research about the factors underlying the gesture of blood donation, in order to increase
Received 6 June 2018; Received in revised form 21 December 2018; Accepted 31 December 2018
⁎Corresponding author at: Polytechnic Institute of Bragança (IPB), Higher School of Health, Department of Therapeutic and Diagnostic Technologies, Avenida D. Afonso V, 5300-121, Bragança, Portugal.
E-mail address:firstname.lastname@example.org(A.J. Nogueira).
1473-0502/ © 2019 Published by Elsevier Ltd.
the number of VNRBD [10,11,13–16].
The motivations underlying the intention of donating blood are a complex network which change over time , or according to the environmental circumstances  as well as after planned strategies with positive impact on the intention of donating blood . Although the prosocial behaviour which includes the altruism and collectivism has been reported as main motivator , other factors such as per-ceived need of blood [15,18], level of knowledge about blood donation [10,14,16], self-esteem and campaigns [11,15,18] have an impact in blood donation. Knowledge about factors underpinning the act of do-nating blood will allow the policy-makers to foresee strategies, mes-sages and social interventions in order to increase the number of VNRBD [11,15].
Although there has been an increasing awareness of the need to donate blood there has been also a decrease in blood donation in sev-eral countries [15,19]. Over the last seven years, the number of blood donors in Portugal decreased by 40%, which is a matter of concern for the Portuguese National Healthcare System . Therefore, there is a need to optimize strategies of recruitment and retention of blood do-nors.
Undergraduate students are a preferred target for blood donation campaigns, as they constitute a young healthy and well-informed group [19,21–27]. The Portuguese Institute of Blood and Transplantation (IPST) has been organizing blood harvesting campaigns in Higher Education Institutions, enrolling undergraduate students. However, the success of such campaigns depends on motivations and attitudes of this particular group towards blood donation. Therefore, it is important to understand this group in regards to their motivations and attitudes towards the act of blood donating. Such knowledge will allow the im-provement of strategies to encourage young people to donate blood voluntarily with no reward.
The aim of this research is to understand the motivations and atti-tudes underpinning the act of blood donating among undergraduate health science students.
2. Materials and methods
This study is a part of a large cross-sectional study carried out at a College of Health Sciences in Northeast Portugal. Regular under-graduate students attending classes duringﬁve weeks between January and February 2017 were eligible for this study (internship students were excluded). From 1140 regular undergraduate students enrolled in this College, 32% (n = 369) were invited to participate from which 2% (n = 7) refused.
This research was approved by the ULSNE Ethical Committee. Informed consent was taken from all participants and adequate proce-dures were implemented to respect the conﬁdentiality and anonymity of the research data.
Data collection tool (DCT) was a self-administered questionnaire designed by the authors and based on a review of the literature about blood donation [15,22,25,27–29]. All students who participated and answered to the questionnaire were informed in advance that their contribution would be voluntary and that all information obtained would be used for the only objective of the research.
For the present analysis we considered four groups of variables. The ﬁrst group included the following sociodemographic variables: gender, age (< 23 and > = 23 years old), degree program (nursing, biome-dical and laboratory science, pharmacy technician, nutrition and
gerontology), year of study (ﬁrst, second or third/fourth) and partici-pation in volunteer activities (yes or no). The second group covered the following general issues related with the act of blood donation: donor status (at least one previous blood donation or never donated blood), father and/or mother are blood donors (yes, no, don’t know) and blood donation campaigns at school (yes, no, don’t know). The third group was applicable only to non-donors and covered questions about reasons hindering blood-donation and about availability to donate at request. The fourth group was focused on speciﬁc information about blood do-nation grouped into two domains: attitudes (ﬁveyes/noquestions) and motivations (eight questions graded on aﬁve-point Likert’s scale“not important”,“slightly important”,“fairly important”,“important”and“very important”) towards the act of blood donation.
2.4. Statistical analyses
The outcome of interest is the blood donation status dichotomized into blood donors (at least one previous donation) and non-donors (never donated blood). The Chi-square test was used to compare groups by donation status in regards to sociodemographic variables, general issues related with the act of blood donating, attitudes and motivations. Multiple logistic regression models were used to assess the association between each attitude and each motivation on the blood donation status (blood donorversusnon-donor). Answers about motivations were re-categorized into two groups: one group included participants an-swering“very important”and the other group included participants who assigned other answer options. We obtained odds-ratio (OR) and re-spective 95% conﬁdence interval (95%CI) adjusted for potential con-founders. All sociodemographic variables and general blood donation issues revealing a signiﬁcant association with blood donation status were considered as potential confounders and they were included in the regression models.
Statistical analyses were done by using SPSS (Statistical Package for the Social Sciences), version 22.0, and signiﬁcance level was set at 0.05.
From 362 participants, 83.4% (n = 302) were female, 83.7% (n = 314) aged less than 23 years old, 27.1% (n = 98) were involved in volunteer activities and the highest proportion of students were en-rolled in the nursing degree program (48.3%; n = 175) and in theﬁrst degree year (47.0%; n = 170). One fourth of students (25.4%; n = 92) reported that their parents were blood donors and a similar proportion (24.8%; n = 90) reported that there were blood donation campaigns at schools they had attended. Only 12.7% (n = 46) of students were classiﬁed as blood donors (at least one previous donation) from which 56.5% (n = 26) are regular donors.
Table 1shows the diﬀerences between donors and non-donors in regards to sociodemographic variables and general issues related with blood donation. Signiﬁcant diﬀerences were found only between groups by age, where older students presented a higher proportion of donors (25.0%versus10.8%; p = 0.012).
From 316 non-donors, 88.0% (n = 278) reported that they are available to donate if requested. The most common reasons for not donating blood were “no one ever asked for donation” for 36.7% (n = 116) and“never thought to donate”for 25% (n = 79) of non-donors (Fig. 1).
There were no signiﬁcant diﬀerences between groups by donation status in regards to attitudes towards the act of blood donation. Almost all donors and non-donors will donate blood to a family relative or friend or after an urgent call for blood. The proportion of donors and non-donors who will donate blood after a blood donation campaign was, respectively, 76.1% and 66.1% (p = 0.239). Among donors and non-donors 15.2% and 21.8% of students (p = 0.403), respectively, will donate blood for monetary reward (Fig. 2).
participants were “shortage of blood stock” for 77.8% of donors and 65.1% of non-donors, and“civic duty”for 64.4% of donors and 40.3% of non-donors (Fig. 3).
The results obtained from logistic regression models are displayed in Table 2. Only age was signiﬁcantly related with blood donation status, therefore age is the only potential confounder considered in the models. Accordingly, none of attitudes has a signiﬁcant impact on blood do-nation status. From all motivations only “be a civic duty” has a sig-niﬁcant impact on blood donation status, such that students that as-signed this motivation as“very important”are more likely to be a donors (OR = 2.58; IC 95%: 1.34–4.99) than their counterparts.
This study showed that among undergraduate health science stu-dents, the proportion of those who had ever donated blood is low (12.7%) and only half of them are regular donors. However, among non-donors, there are a large proportion of students who reported to be available to donate blood. Indeed, the majority of both donors and non-donors were willing to donate blood to a relative, or a friend or even after an urgent call for blood. It is noteworthy that the main reasons for not donating blood were “no one ever asked for donation”and "never thought to donate". Overall donors and non-donors are very similar in regards to attitudes towards to the act of blood donation and the only
motivation that appears related with the donation status is to feel blood donation as a civic duty.
In our setting, the proportion of who had ever donated blood is lower than the one reported in other similar settings where the pro-portion of blood donors among undergraduate students varied between 18% and 41% [19,21–24,26,27]. Such aﬁnding highlights the need of planning strategies in order to motivate undergraduate students in our setting towards blood donation. In accordance with other studies as-sessing blood donation among undergraduate students [22,24,27], the main reason for not donating in our setting was“no one ever asked for donation”. According to the answers of non-donors included in our study, they don’t reject the act of blood donation. Indeed, almost all students will donate blood to a family member or friend or after an urgent call for blood. Thisﬁnding foresees recruiting strategies of new donors based on well planned campaigns and advertising methods fo-cused on the emergent need of blood donation. Such strategies should highlight the social value of blood donation, as anyone could need blood, including family members or friends. Taking into account that undergraduate students are enrolled in degree programs, those re-sponsible in planning academic subjects could play an important role in increasing awareness regarding blood donation among students.
Several studies have been published mentioning the factors that determine the intention to donate blood among undergraduate students [19,21–27]. The knowledge about such factors will allow us to motivate
Sample characteristics by blood donation status.
n (%) p.value
Gender Male 10 (16.7) 50 (83.3) 0.313
Female 36 (11.9) 266 (88.1)
Age (years) < 23 34 (10.8) 280 (89.2) 0.012
> = 23 12 (25.0) 36 (75.0)
Degree program Nursing 29 (16.6) 146 (83.4) 0.139
Biomedical and laboratory science 7 (10.4) 60 (89.6)
Pharmacy technician 5 (7.5) 62 (92.5)
Nutrition 2 (5.3) 36 (94.7)
Gerontology 3 (20.0) 12 (80.0)
Degree year attendance 1st 20 (11,8) 150 (88,2) 0,757
2nd 10 (15,4) 55 (84,6)
3rd e 4th 16 (12,6) 111 (87,4)
Fez/faz voluntariado Sim 14 (14,3) 84 (85,7) 0,600
Não 32 (12,2) 230 (87,8)
Pais dadores Sim 13 (14,1) 79 (85,9) 0,769
Não /Não responde/Não sabe 33 (12,2) 237 (87,8)
campanhas na escola Sim 15 (16,7) 75 (83,3) 0,263
Não/Não responde/Não sabe 31 (11,4) 241 (88,6)
Bold values mean that the p value is lower than 0.05.
Fig. 2.Attitudes towards the act of donating blood among donors (n = 46) and non-donors (n = 316).
Fig. 3.Motivations towards act of blood donation among donors (n = 46) and non-donors (n = 316).
Results from logistic regression models (donorsversusnon-donors).
Attitudesb Are you willing to donate blood if you know the receptor? 1.62 (0.54
–4.83) Are you willing to donate blood after an urgent call for blood? 0.88 (0.10–7.67) Are you willing to donate blood to a family relative or a friend? 0.60 (0.07–5.29 Are you willing to donate blood after a blood donation campaign? 1.68 (0.82–3.48) Are you willing to donate blood for monetary reward? 0.67 (0.28–1.57)
Motivationsc Self-realization 1.87 (0.97
Control of one's own health 0.82 (0.41–1.64)
Be a civic duty 2.58 (1.34–4.99)
Quality of care in blood donation centers 1.19 (0.62–3.29) Proximity of blood donation centers 1.27 (0.61–2.68) compatible timetable with blood donation centers 0.64 (0.27–1.52)
Be a member of a group 1.52 (0.54–4.26)
Shortage of blood stock 1.96 (0.92–4.14)
a Adjusted for age.
b Reference group: students answering “no”.
young, healthy and informed people to donate blood.
Self-satisfaction [24,27], public promotion , moral responsi-bility and altruism  are the motivations towards to blood donation more frequently reported in previous research. A large proportion of undergraduate students in our setting reported self-realization, civic duty and the shortage of blood stock as motivations to donate blood. The act of blood donation has been related to moral superiority and can be based on feelings of responsibility and duty . Such issues become keystones within a system of sourcing blood from voluntary non-re-munerated blood donors . Blood donation campaigns should em-phasize the civic duty of all members of society in increasing blood stock.
Fear of diseases due to the act of blood donation has been con-sidered a factor hindering blood donation [24,25]. Low level of knowledge about blood donation has been considered a factor with negative impact on the act of blood donation . In our sample, the proportion of students who reported health concerns was low (2.8%). However such aﬁnding still reveals the need of information about the safety of blood donation.
The proportion of donors in our sample is low, particularly regular donors, which could be a limitation when factors driving blood dona-tion are under discussion. Future research should be conducted in a larger number of donors, in order to gain more detailed knowledge about this issue in our setting.
This study revealed that more than 80% of undergraduate health science students in our setting had never donated blood, but they are available to do so blood on request. According to Portuguese legisla-tion, blood donation is a civic duty for all healthy citizen allowing to meet blood needs for the community . Therefore, campaigns and advertising methods describing the gesture of blood donation as an important civic duty overcoming the emergent need of blood donation and on the could play an important role in the recruitment of new donors among undergraduate students.
Conﬂict of interest
 World Health Organization, International Federation of Red Cross and Red Crescent Societies. Towards 100% voluntary blood donation: a global framework for action. [Internet] Available from: 2010http://www.who.int/bloodsafety/publications/ 9789241599696_eng.pdf?ua=1.
 Hou GJ, Zhou F, Tian Y, Ji HQ, Zhang ZS, Guo Y, et al. Predicting the need for blood transfusions in elderly patients with pertrochanteric femoral fractures. Inj J Care Inj 2014;45(12):1932–7.
 Pieri M, Nardelli P, De Luca M, Landoni G, Frassoni S, Melissano G, et al. Predicting the need for infra-operative large volume blood transfusions during thoraco-ab-dominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2017;53(3):347–53.  Umemura T, Nakamura Y, Nishida T, Hoshino K, Ishikura H. Fibrinogen and base
excess levels as predictive markers of the need for massive blood transfusion after blunt trauma. Surg Today 2016;46(7):774–9. [Internet], Available from:.https:// link.springer.com/content/pdf/10.1007%2Fs00595-015-1263-7.pdf.
 Conner SN, Tuuli MG, Colvin R, Shanks AL, Macones GA, Cahill AG. Accuracy of estimated blood loss in predicting need for transfusion after delivery. Am J Perinatol 2015;32(13):1225–30. [Internet], Available from: https://www.thieme-connect.de/ DOI/DOI?10.1055/s-0035-1552940.
 Parker CS, Tsai J, Siddiqi AE, Atrash HK, Richardson LC. Meeting the emerging public health needs of persons with blood disorders. Am J Prev Med 2014;47(5):658–63.
 Chari A, Arinsburg S, Jagannath S, Satta T, Treadwell I, Catamero D, et al. Blood transfusion management and transfusion-related outcomes in daratumumab-treated
patients with relapsed or refractory multiple myeloma. Clin Lymphoma Myeloma Leuk 2017. 2017/10/22.
 Patel SV, Brennan KE, Nanji S, Karim S, Merchant S, Booth CM. Peri-operative blood transfusion for resected colon cancer: Practice patterns and outcomes in a popula-tion-based study. Cancer Epidemiol 2017;51:35–40. 2017/10/17.
 Williamson LM, Devine DV. Challenges in the management of the blood supply. Lancet 2013;381(9880):1866–75. [Internet]. 2013/05/28, Available from:.http:// www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60631-5/fulltext.  Alﬁeri S, Guiddi P, Marta E, Saturni V. Economic crisis and blood donation: How are
donors’motivations changing? Transfus Apher Sci 2016;54(3):396–400.  van Dongen A, Ruiter R, Abraham C, Veldhuizen I. Predicting blood donation
maintenance: the importance of planning future donations. Transfusion 2014;54(3 Pt 2):821–7. 2013/09/17.
 Masser BM, White KM, Hyde MK, Terry DJ. The psychology of blood donation: current research and future directions. Transfus Med Rev 2008;22(3):215–33.  Abasolo I, Tsuchiya A. Blood donation as a public good: an empirical investigation
of the free rider problem. Eur J Health Econ 2014;15(3):313–21. 2013/06/26.  Guiddi P, Alﬁeri S, Marta E, Saturni V. New donors, loyal donors, and regular
do-nors: Which motivations sustain blood donation? Transfus Apher Sci 2015;52(3):339–44.
 Martin-Santana JD, Beerli-Palacio A. Intention of future donations: a study of do-nors versus non-dodo-nors. Transfus Med 2013;23(2):77–86.
 Charbonneau J, Cloutier MS, Carrier E. Why do blood donors lapse or reduce their donation’s frequency? Transfus Med Rev 2016;30(1):1–5. 2016/01/15.  Balegh S, Marcus N, Dubuc S, Godin G, France CR, Ditto B. Increasing nondonors’
intention to give blood: addressing common barriers. Transfusion 2016;56(2):433–9. 2015/11/05.
 Bednall TC, Bove LL. Donating blood: a meta-analytic review of self-reported mo-tivators and deterrents. Transfus Med Rev 2011;25(4):317–34.https://doi.org/10. 1016/j.tmrv.2011.04.005. [Internet], Available from:.
 Papagiannis D, Rachiotis G, Symvoulakis EK, Anyfantakis D, Douvlataniotis K, Zilidis C, et al. Blood donation knowledge and attitudes among undergraduate health science students: a cross-sectional study. Transfus Apher Sci 2016;54(2):303–8.
 Serviço Nacional de Saúde. Transparência [Internet]. Available from:.https:// www.sns.gov.pt/transparencia/.
 Gebresilase HW, Fite RO. Knowledge, attitude and practice of students towards blood donation in Arsi University and Adama Science and Technology University: a comparative cross sectional study. BMC Hematol 2017;17:20. [Internet], Available from:. https://bmchematol.biomedcentral.com/track/pdf/10.1186/s12878-017-0092-x?site=bmchematol.biomedcentral.com.
 Baig M, Habib H, Abdullah HH, Faisal TA, et al. Knowledge, misconceptions and motivations towards blood donation among university students in KSA. Pak J Med Sci 2013;29(6):1295–9. 2014/02/20.
 Gazibara T, Kovacevic N, Maric G, Kurtagic I, Nurkovic S, Kisic-Tepavcevic D, et al. Factors associated with positive attitude towards blood donation among medical students. Transfus Apher Sci 2015;53(3):381–5. 2015/08/25.
 Mamatya A, Prajapati R, Yadav R. Knowledge and practice of blood donation: a comparison between medical and non-medical Nepalese students. Nepal Med Coll J 2012;14(4):283–6. 2012/12/01.
 Mishra SK, Sachdev S, Marwaha N, Avasthi A. Study of knowledge and attitude among college-going students toward voluntary blood donation from north India. J Blood Med 2016;7:19–26. [Internet]. 2016/04/07, Available from:.https://www. dovepress.com/getﬁle.php?ﬁleID=29468.
 Elias E, Mauka W. Knowledge, attitudes, practices, and factors associated with voluntary blood donation among university students in Kilimanjaro, Tanzania 2016. 2016 8546803. Available from:http://downloads.hindawi.com/journals/ jbt/2016/8546803.pdf.
 Anwer MO, Ul Fawwad SH, Anwer S, Ali A. Attitude toward blood donation among medical and nonmedical students across Karachi. Asian J Transfus Sci
2016;10(2):113–7. [Internet]. 2016/09/09, Available from:.http://www.ajts.org/ article.asp?issn=0973-6247;year=2016;volume=10;issue=2;spage= 113;epage=117;aulast=Anwer.
 dos Henriques TERM. Fatores que condicionam a dádiva de sangue: Estudo empírico aplicado a estudantes universitários de Coimbra [Internet]. Faculdade de Economia da Universidade de Coimbra, Available from:. 2014https://estudogeral. sib.uc.pt.
 Matos A, Sousa AP, Araújo F, Maia F, Esteves JG, Pinheira MA, et al. Manual de Triagem de Dadores de Sangue IP [Internet], Available from:. Instituto Português de Sangue e da Transplantação; 2014http://ipst.pt/ﬁles/IPST/INFORMACAO_ DOCUMENTACAO/ManualTriagemDadoresSangue2014.pdf.
 Buciuniene I, Stoniene L, Blazeviciene A, Kazlauskaite R, Skudiene V. Blood donors’ motivation and attitude to non-remunerated blood donation in Lithuania. BMC Public Health 2006;6:166. [Internet]. 2006/06/24, Available from:.https:// bmcpublichealth.biomedcentral.com/track/pdf/10.1186/1471-2458-6-166?site= bmcpublichealth.biomedcentral.com.
 Assembleia da República. Lei no36/2012. Diário da República. 2012. p. 4701